Tuesday, January 16, 2007

We are a sleep-deprived nation, and it puts nearly all of us at risk — in the gym, in the sack, on the job. The really good news: The cure takes just 8 hours By: Peter Moore, Men's Health Photographs by: Chris Buck

This is a story about nothing. Its subject is you, unconscious. And me, striving for unconsciousness. It's about what's happening to us between the hours of 10:15 p.m. and 7 a.m., when we should be sleeping.

Not a lot going on between those sheets, you say? I say, Wake up! Sleep heals. Sleep calms. Sleep rebuilds. Sleep provides an opportunity for the penile exercise you don't make time for during your busy day. Sleep shuts down your body and awakens your mind. In addition to being vital, it's also bizarre and contradictory — it's the inactive activity, the void you fill by dreaming up entire worlds, the state of nothingness that means everything. Weird.

The science of sleep is only about 40 years old, and among the things yet to be discovered by researchers is...um...how sleep works, exactly. That, and how to define it. But that's sleep for you: full of mysteries and surprises.

Maybe the most surprising thing of all is that 60 million Americans do it very poorly, suffering any number of sleep disorders . And more than half of the afflicted are men, according to James Rowley, M.D., director of the sleep-disorders center at Harper University Hospital, in Detroit. Many of these guys would deny they have a problem, and those who acknowledge it probably aren't being helped. "Women get motivated when they're sleepless," says Dr. Rowley. "Men are silent."

As the years pass, the odds are that these bleary-eyed, silent guys will get even less sleep, and touch off a cascade of other miserable conditions. If sleeplessness doesn't put a sudden end to your morning commute, it can dim your brainpower and success on the job. It can sour the report your doctor gives you on your cardiac risk, make you fatter, and set you up for diabetes. It will make you fight more with your wife, kids, and house pets. Sleeplessness is the symptom that makes its underlying cause — stress, depression, pain, or all of the above — even worse.

For 15 years, I've been searching for a decent night's sleep, and I've had a major health nightmare along the way. Even though I was a committed exerciser with good cholesterol counts, I built a major arterial blockage a few years back. And it came after a 2-year bout of wretched insomnia.

Now, when I lay me down to sleep, I know the stakes are high. True for me, true for you, too, brother. For our own good, we all need to rest a little easier.

SLEEP IN THE LAND OF SIN

Nowhere is that more evident than in Las Vegas, where the wee hours take on a special pathology. I went there to spend a night in the casinos, and William Thompson, Ph.D., a gambling expert at the University of Nevada at Las Vegas, was my coach. When I asked him how he'd chosen that academic specialty, he said, "When you're in Siberia, study polar bears."

And as we walk through the MGM Grand casino, they're snarling everywhere. He shows me 20 ways Las Vegas casinos push their advantage — from having people convert their hard- earned cash into worthless plastic chips before they bet to making it hard to find the exit door.

Then, as the clock ticks, the casinos make their shrewdest bet of all: that sleep deprivation will make their customers stupid.

To understand why, let's take a stroll through a sleepy human brain. Our tour guide here is William Killgore, Ph.D., a major in the Medical Service Corps of the U.S. Army, based at Walter Reed Army Institute of Research. He works in the fascinating area of sleep, cognition, and emotional intelligence. He explains that as Homo sapiens developed from ape to man, our brains developed, too — particularly a structure known as the prefrontal cortex, which took information from our senses, mingled it with our memories, and added shadings of emotion and understanding. As man seized dominion over all the earth, our prefrontal cortexes — the font of our humanity, of reason — led the way.

No wonder the casinos are against it.

The house's advantage is to reduce you to a more primitive beast. Glucose metabolism — the rate of energy burn in your prefrontal cortex — slows down as night turns to day. Uh-oh. A Neanderthal buzz, originating in knuckle-dragging parts of the brain, supplants your higher faculties. Evolution slips into reverse; you become less human.

So much the worse if the beast is up past his bedtime, goes to a strip show, orders a cocktail or two, and smokes a cigar. As Killgore puts it, "Your prefrontal cortex needs a break, so it shuts down. You have less emotional flexibility. You reduce your ability to make effective decisions."

When this happens in the wee hours, Las Vegas is ready: You're lost in an artificial world. Table stakes rise as the evening goes on. The $5 minimums of the afternoon rise to $20, then $50, and suddenly each hand has financial consequences; if you play long enough, the odds will get you. And these are the guys you'll see along the Strip the next morning, still wearing last night's clothes, their prefrontal cortexes aroused by coffee and stress hormones, wondering what hit them last night.

Here's what: They gambled and lost on a mechanism they may only be dimly aware of — the circadian rhythms that run their days, their whole lives. When that system orders you into bed, you'd better listen: It's just trying to keep you out of trouble.

NO SHAME IN SLEEPING IN

I don't mean to pick on Vegas. Men who go there are fully aware of the risks and undertake them anyway — the odds and their prefrontal cortexes be damned. And at least the strippers pretend to be friendly. But the casino industry is an example of foolish wagers being placed and lost all across our society. Most men consider sleep a waste of time, and bet their lives they can get along without it.

"Who needs sleep?" asks the Coors beer commercial. "I only get 4 hours a night," brags your coworker, echoing Thomas Edison, antisleep agitator and inventor of the lightbulb — a contributing factor in our drowsy lives. And the rest of us use the language of shame when we "sneak off for a nap" or point out that a coworker was "asleep at the wheel." And our sleep suffers for it. According to a survey by the National Sleep Foundation, each of us averages 2 hours and 12 minutes less sleep nightly than our great-grandparents did in 1910. And it isn't just because of high-quality late-night TV.

The 2003 American Time Use Survey shows that we're trading sleep for all kinds of things, most predictably work ("Good morning, boss!" followed, 10 hours later, by "Should we order Chinese?"), but also entertainment ("Dancing with the Stars is on!") and commuting ("I can't wait to get back on I-70 to Kansas City tomorrow!").

Think about that last one for a minute. By exchanging rack time for road time, we're almost guaranteeing that we'll add to the one-third of all car accidents attributable to drowsy driving. Worse yet, after 5 nights of partial sleep deprivation — does that sound like your workweek? — three drinks at happy hour will have the same effect that six would have had if you'd been well rested. And then you drive home. You might even make it.

That's why, at the end of most of his interviews (including one with me), William Dement, M.D., Ph.D. — a combination Christopher Columbus/Cassandra of sleep research — practically shouts his admonition: Drowsiness is a warning!

Dr. Dement, who mans the sleep desk at Stanford University, has the personal scare story to prove it. Once he was met by a chauffeur at the airport, to give him a ride to a big meeting of sleep docs. The guy was overweight, and he had grown a beard to conceal a smallish chin. You've probably seen guys like that, too. Well, don't get into their cars for a nighttime drive.

Dr. Dement's chauffeur was exhibiting the classic physical symptoms of sleep apnea, a disorder that closes an afflicted man's airway up to 300 times a night and causes monumental health problems in the process. Dr. Dement instantly saw the danger and aggressively conversed with him. Then they pulled onto a road high above the Columbia River gorge, the driver slumped, the car veered across the oncoming traffic lane, and...the good doctor shouted, the driver jerked the wheel, and obituary writers were deprived of a deliciously ironic lead.

And Dr. Dement is still alive to deliver the warnings.

TRADING SLEEP FOR WORK

His cry has swelled into a chorus. For a while, every time I called a sleep expert for this story, they refused to answer my questions until they were finished venting over the commercial airline wreck of Comair Flight 5191 out of Lexington, Kentucky, in which both the pilots and the man in the control tower were sleep deprived. Consider the lonely vigil that air-traffic controller will conduct every night from now on as he lays head on pillow.

Each of us has plenty in common with that poor soul. If we trade sleep for work, sleep for commuting time, sleep for computer time, we multiply the risk that we'll make a mistake that kills. If we're very lucky, we'll take out only ourselves.

Am I belaboring the obvious? Sleepy driving, after all, is rather like drunken sex or Washington lobbying — nobody expects anything good to come of it. But it's only the most common way that poor sleep can mess up your whole waking life.

It may help, here, to take a look at a good night's sleep, so you know what you're missing when you have a lousy one.

All day long, you're burning glucose, the fuel that drives everything you do. One by-product of that inferno is a neuro-transmitter called adenosine, which binds with receptors in your nervous system, telling it to shut down for the night. (That's why exercisers sleep better: They burn more glucose.) Reinforcing the effect of adenosine is another energy regulator: melatonin. It also kicks in toward bedtime, so you yawn, hit the power button on the remote, and head into your bedtime rituals. Do them right and you reach the bed ready for sleep. (Sex works, too: The chaser for intercourse is the hormone oxytocin — a profound sleep inducer. It's the enemy of pillow talk and cuddling, where men are concerned.)

The bridge into unconsciousness is described in stages, which reflect the pattern of electrical impulses recorded in the sleeping mind. Alpha waves hum in the calm, sleepy brain, but the instant theta waves show up on the electroencephalograph recorder, you begin shutting down your senses. This is stage one, light sleep. If your wife asks you to take out the garbage, you'll still hop to it.

Five minutes later, though, and she's out of luck. Your senses lock down, and you realize full wet-noodle status. Stage two comes quickly, and the electrical activity is vastly different on the printout. You're falling fast now, into the deep sleep of stages 3 and 4. The latter is when your body secretes growth hormone, to reward you for any muscle-building activity you might have engaged in during the day.

Next comes rapid eye movement (REM) sleep, which Dr. Dement famously studied by inviting a chorus line of Rockettes into his New York apartment sleep lab. (There's a line you haven't tried: "I'm a sleep researcher, and I wonder if I might observe you...") Your muscles are now utterly paralyzed, your mind utterly alive. Those pursuit dreams where the grizzly leaps but you can't run? That's REM sleep.

If you forget to set the alarm, there's no need to worry, because as you run through your supply of sleep-inducing melatonin, it's replaced in your bloodstream by a surge of cortisol. It urges you to get the hell out of bed.

So you sit up in a stark panic over the 8 a.m. staff meeting and spot the rising sun out your bedroom window, and your pineal gland shuts down melatonin production entirely. Like Dracula, the gland shies from the sunlight, waiting for dark to turn on the melatonin supply once more and bed you down.

A TALE OF TWO SLEEP CHARTS

Okay, that's the Sleeping Beauty version of the overnight story. One phase flows neatly into the next, uninterrupted, and the therapeutic process sweeps inevitably toward morning light.

Then there's the way I sleep, which is kind of like the way Reggie Bush runs: all over the place. I found this out at the University of Pennsylvania sleep lab, which occupies a couple of floors in the Sheraton Hotel near the campus in Philadelphia. That's where I went through the ordeal of polysomnography; in its way, it too was a testament to the power of the sleep drive. I checked into the lab around 8:30 p.m. one night last summer and was met by a sweet, slight sleep technician named Amber.

She wired me like an NSA stakeout — three brain scanners on my scalp, a breath clip under my nose, straps to monitor chest and torso movements, a movement sensor on my leg to see if I do the midnight jig, and a finger pincer to track my oxygen levels. Thus encumbered by electronics, with a video cam further invading my privacy, I closed my eyes.

Amber woke me up at 6:30 a.m., right after an active half hour of REM sleep. The tapes show what a jumpy thing I am at night. Amber told me that my periodic limb movements might have an arousing effect, but not the kind I forward to. If this is rest, no wonder I don't feel refreshed in the morning.

Nor was Amber complimentary about my other sleep patterns. She noted my hypopneas —brief cessations of breath — which aren't a problem in a "relatively young man like me" but might become a problem later in life. This sounded like Dr. Dement's drowsy driver. But I'm nothing like that guy.

And yet, there was Amber telling me that I need to watch out, too. It could be that my throat muscles are relaxing just enough in sleep to affect my airway. The glass of wine I like to have with dinner could encourage that. Plus, I've been told I have a relatively small jaw and luxuriant tongue tissue (hey, some people consider that an advantage), so maybe I'm not so far off from apnea land.

I left the lab dazed, not only from my rough night under analysis, but also from the news that there's a lot more going on in the night than I ever realized. Later on, I met with Richard Schwab, M.D., of the Penn sleep center, and he wasn't too concerned by any of it, opining that maybe I just think about my sleep too much. He wasn't the first to suggest that. Many of the researchers I interviewed noted the tendency of chronic insomnia sufferers to ruminate on their sleeplessness. Which I understood completely: The hungry obsess over food, the sleepless focus on their eyelids — open or shut.

THE SLEEP PROFESSIONALS

In Salt Lake City, where I attended the convention of the Associated Professional Sleep Societies, I picked up a useful perspective on my obsession. I'll admit that, at times, the lectures inspired delightful naps on the lawn outside the Salt Palace. But the researchers issued their share of wake-up calls, too.

One presentation, for instance, quoted the Austrian neurologist and psychologist Viktor Frankl. During World War II, he was deported to Auschwitz and eventually spent time in four concentration camps. He knew a few things about nightmares. Frankl's observation: "Sleep is like a dove which has landed near one's hand and stays there as long as one does not pay any attention to it; if one attempts to grasp it, it quickly flies away."

For the past 15 years, I've done everything I can to nail that sucker to my bedpost. I've drugged him. I've dusted him with stinky herbs. I've invited him to share a glass of wine with me. And lately I've enlisted an army of sleep docs to grant me the peace just to let him land.

But once that bird starts to fidget, it's damned hard to make him sit still.

I can trace my own difficulties to one blissfully sleepless night in 1990, at Michael Reese Hospital, in Chicago. That's when my son Jake was born. One estimate holds that a new baby results in 400 to 750 hours of lost sleep for his parents in the first year; between Jake and his brother Tyler, I'm officially down at least a thousand hours. More, if you pack on the added responsibilities of supporting a family, a boss, and a mortgage, plus worrying about the Cubs. You can see I've had way too much on my mind to sleep.

But the conference in Salt Lake City reinforced how critical it is to lure Frankl's bird to my bedside. Name almost any chronic threat to a man's health, and sleeplessness plays a role. Sometimes a very big one.

One hot area of research is the connection between sleep and weight gain, and I'm not just talking about the infamous Ambien abusers who hoover their fridges. Researchers at the University of Chicago have been tracking the correlation between sleep and two hunger hormones: ghrelin, which urges your body to chow down, and leptin, which tells it to push back from the table. They recruited 12 young men and limited them to 4 hours of sleep on 2 consecutive nights. It was as if they'd cut their hunger brake lines and attached a brick to their eating accelerators: ghrelin was up 28 percent, leptin down 18 percent.

Sanjay Patel, M.D., of Case Western Reserve University, in Cleveland, gave a fascinating presentation at the conference in which he demonstrated that people who get only 5 hours of sleep a night weigh more than longer sleepers at every age. Think of all the ghrelin surging through their veins, and the extra hours they have to eat crullers.

And in fact, the young men in the University of Chicago study who had the greatest ghrelin and leptin swings were the ones who, in surveys, most craved cake, candy, cookies, ice cream, pastry, chips, salted nuts, bread, pasta, cereal, and potatoes. If you salivated when you read that list, take a look at how much sleep you got last night.

Another group of researchers at the University of Chicago demonstrated that just 3 nights of fragmented sleep — the tossing- and-turning variety — made glucose tolerance and insulin sensitivity plummet. Both of those, long-term, will elevate blood sugar, which can damage the tiny capillaries that carry oxygenated blood to your heart, your eyeballs, and your penis.

If that doesn't worry you, go ahead: Stay up late thumbing the remote. And keep doing it. There will be plenty of time to consider the consequences on the job tomorrow.

THE STUDY OF SLEEP DEPRIVATION

Killgore's most recent endeavor has been to round up young, male military recruits, torment them to wakefulness in various ways, and then administer tests that probe for many of the things that get you through the workday: making smart choices, learning new skills, working with people, pushing past failure, laughing off Dilbert moments. Sleep deprivation sabotages them all.

Your greatest fear on the job, then, might be that your boss — or worse yet, a rival — is getting enough sleep. Against that advantage, your sleepy ass doesn't stand a chance.

A lot of sleep research seems to begin with being mean to rats. In Salt Lake City, I met many pleasant, intelligent young people who had devised ingenious ways to stress out rodents — forcing them to swim against their will, or shocking their little pink feet — to see how it affected their shut-eye.

My rat empathy was particularly engaged by tests involving what the researchers called "social defeats." For instance, there's the experiment in which a young, naive rat was dropped into a cage along with an attractive female rat. After the two had sniffed and nuzzled a bit, the scientists introduced an older, aggressive male rat into the cage. This rat bastard made life hell for the younger male rat, until the young guy exposed his belly in utter defeat. He slept lousy at night, poor rodent.

Oddly enough, that perfectly describes my life in a job I once had. I reacted like the caged rat: by showing my belly and losing sleep. Like, 2 years' worth. I feared that the circles under my eyes might knit into a noose around my neck. A shrink prescribed an antidepressant/sleep inducer called Trazodone, and it got me through the dark nights.

Fortunately, the rat boss was chased off by corporate, and my life instantly improved — day and night. The spirit returned to my exercise, and I ran marathons in Vermont and New York City. I was quite the physical specimen, in fact, except for the plaque that had been building in the left anterior descending artery of my heart — a passageway aptly nicknamed "the widowmaker." I had no clue about it until I hopped on my bicycle in Martha's Vineyard, intent on a 50-miler. Chest pain stopped me, nearly for good.

I never had a heart attack — just a really good scare. And the angioplasty and stent now seem to have fixed me up just fine.

I feel better than ever, and my heart indices are superlative.

But nothing can relieve the aching question I have about why I, of all people, developed the blockage in the first place. No doctor in the world would point to my 2 years of sleepless hell as an absolute cause; it might have been genetics, or plain bad luck. But from what I now know, I wonder if insomnia almost choked the lifeblood out of me.

HOW SLEEP HELPS YOUR HEART

The old lion of the field, Dr. Dement, quite nearly wrote my epitaph when he pointed out, in the introduction to his compelling bedtime saga, The Promise of Sleep, that "if someone you know has had a heart attack, there is a good chance (especially if the victim is young) that an undiagnosed sleep disorder contributed to the problem."

How does sleep affect your heart health? Let me count the ways.

Janet Mullington, Ph.D., who hangs her mortarboard at Harvard medical school, contributed to a study that linked sleep loss with inflammation — the hot young thing cardiac researchers have been chasing around for the past decade. Essentially, if your blood carries elevated inflammation markers, your heart is in danger. "We've seen a connection between total sleep deprivation and an increase in white blood cells, interleukin-6, and C-reactive protein," she told me, naming a few horsemen of the inflammatory apocalypse. "It even happens with partial sleep deprivation."

Her study also showed increases in blood pressure and heart rate when people are denied sleep. Hypertension is one of the factors that can cause arterial plaques to rupture, and the next step is the blood clots that race to a narrowing in a heart artery, and kill.

But not me. Or at least, that's my plan.

I'm happy to report that for the sleep starved, there is a relatively new solution available, and it has nothing to do with that Lunesta butterfly alighting on my brow, nor inviting the Rozerem beaver into bed with me. (Not that I'm antidrug; many sleep docs I spoke with called the current generation of drugs safe and effective, especially when you compare them with the barbiturates that snuffed Marilyn Monroe and Elvis.)

The cure du jour for insomnia is cognitive behavioral therapy (CBT). A 2006 study revealed that it's as effective as a sedative in inducing sleep. The best news is that, unlike pills, which stop working when you stop swallowing them, CBT encourages sleep long after the sessions have ended.

Michael Sateia, M.D., of the Dartmouth-Hitchcock Medical Center, in Lebanon, New Hampshire, is leading the way toward getting more practitioners trained in CBT. The bedroom hell he describes among his insomniac patients has much in common with the one I've experienced during my worst spells. The bed, he told me, can become a negative place. Instead of evoking warm and relaxing feelings, it can arouse tension and negative expectations. Dr. Sateia told me, "I've had patients whose hearts literally pounded when they even looked at their beds."

It turns out that one of the biggest enemies here is the otherworldly glow of the alarm clock. Even those dimly glowing numbers can mess with your pineal gland, which is extraordinarily sensitive to light. You see the digits 3:14 a.m., and it thinks, Sunrise! The resulting cortisol flow can help fuel the rumination that keeps insomniacs awake until dawn actually comes.

The coming of the true dawn is nothing to be trifled with, either. On the floor of the convention hall in Salt Lake City, I met Larry Pedersen, the founder of the company that produces the Litebook, a lightbulb array he told me could help manage my melatonin levels. "It can give you more energy during the day," Pedersen told me with evangelical fervor, "and a full burst of melatonin at night, when you really need it."

I was ready to wave him off, until he cited chapter and verse on the studies that show how light of a certain amplitude can manage melatonin levels — shutting it down in the morning, so it can build up better in the evening. Bright sunlight will do that. (Seen any recently?) A light box will, too. I took a fair amount of abuse in my office for using one — until I recounted the melatonin knockout punch it delivered at night.

CBT can also help, by using stimulation control before bed — no caffeine within 12 hours of bed, no wine with dinner, and nothing too exciting (WWE, for instance) in the bedtime hour. You keep to a regular schedule of waking, and maybe even push bedtime to build sleep pressure. You don't hit the hay until you're certain it won't hit back.

CHANGING THE NIGHTLY ROUTINE

Naturally, I arranged for a few CBT sessions myself, and found instant progress with a psychologist named David Glosser, Sc.D., based in Allentown, Pennsylvania. He proved his bona fides with me when, in the midst of a barrage of personal questions, he asked which side of the bed I sleep on. Before I could answer, he said, "The left. All guys sleep on the left." He noted that the left arm — your free one, when you roll to the right — is the hairy, horny one men initiate sex with, because it's hooked into the hairy, horny right side of the brain. Guilty as charged.

Glosser changed my bedtime routine, encouraging me to stay up a little later, so that when I fell into bed, I'd be more likely to fall straight to sleep. And he asked my wife and me to switch sides of the bed, to change things up; now I'll look forward to her left hook. And he insists that if I'm not sleeping, I should leave the bed. But not for online poker. Reading time will benefit.

The most important thing he did for me, though, was change my outlook toward sleep. He broke my habits of obsession and worry, and helped me just let the night be. In essence, CBT renovated my bedroom, and my attitude, into a zone of relaxation and peace.

Just the place for Frankl's bird to settle for an evening, in fact.

So, what happened to me that night, in Vegas? I was all psyched up, ready to gamble. I'd set aside a pot to blow, and approached the roulette wheel, lauded as a simple place to lay down a bet and enjoy the action. But for me, stack after stack vanished into the black hole at the croupier's elbow. So I moved on to blackjack, which carries the best odds in the casino. I'd had a little luck at it that afternoon, when the stakes were lower. I won a few big hands that night, but soon my chips disappeared.

I'd imagined an all-night session, running up my totals and witnessing the drama of Vegas till dawn. But I'd busted out before midnight. What to do?

My prefrontal cortex knew the drill. I walked slowly, then with determination, toward the elevators that would carry me upstairs, to my room. I was headed for a good night's sleep.